Ruminations by a non-academic general surgeon from the heart of the rust belt.

Monday, September 21, 2009

War on Obesity

Cleveland Clinic CEO Toby Cosgrove MD has been the target of a media firestorm lately over recent remarks he made to the NY Times about morbid obesity in this country. He averred that, given legal protection, he would seek to limit the hiring of the morbidly obese at his hospital.

Which is why it is so striking to talk to Delos M. Cosgrove, the heart surgeon who is the clinic’s chief executive, about the initiative. Cosgrove says that if it were up to him, if there weren’t legal issues, he would not only stop hiring smokers. He would also stop hiring obese people. When he mentioned this to me during a recent phone conversation, I told him that I thought many people might consider it unfair. He was unapologetic.

“Why is it unfair?” he asked. “Has anyone ever shown the law of conservation of matter doesn’t apply?” People’s weight is a reflection of how much they eat and how active they are. The country has grown fat because it’s consuming more calories and burning fewer. Our national weight problem brings huge costs, both medical and economic. Yet our anti-obesity efforts have none of the urgency of our antismoking efforts. “We should declare obesity a disease and say we’re going to help you get over it,” Cosgrove said.

This elicited quite the backlash from the local and national community and Dr Cosgrove eventually apologized for any implied hurtful intent. But yesterday in the Plain Dealer he wrote an op-ed further clarifying his stance. I give the guy credit; he's taken on a topic that makes a majority of Americans uneasy. Over 60% of Americans are either overweight or obese. This isn't some negligible, dark corner, universally comndemned social issue like crack cocaine or drunk driving. It's unfortunately all too pervasive. I like how he drives home the point that personal accountability has to be a major component of any meaningful health care reform. Just as campaigns to reduce smoking and drunk driving were effective using both information/instructional techniques along with more sensationalistic ads meant to ostracize and demonize undesired behaviors, Dr Cosgrove is calling for the same societal commitment to the fight against obesity. I don't see anything controversial about that. I'm just worried that how well this message is received will be contingent on what number you see when you look down at the scale in your bathroom...

22 comments:

I concur, partly, with his statements. I think we've been accepting of morbid obesity far too often and only encourage further weight gain. If people knew how hard it was to take care of a morbidly obese patient, the extra staff required to just turn them to keep from getting pressure sores, the additional equipment, the lifting chairs, the difficulty performing operations, etc. they might understand why some feel they should be paying more. Whenever I see that a patient has to be turned in any position other than supine who'd BMI is > 35, I cringe. We call for extra help, which takes away from other duties, we have trouble getting them positioned correctly or getting them on the bed at all (supine to prone positioning). Our country shuns personal responsibility for this problem for which I don't understand.

Just a sneaky way to get rid of minorities... And some of the BEST ICU Nurses have BMIs in the 30-Something range..you know I'm preachin Truth Buckeye... And not to bash Y'all Rust Belters but umm Y'all grow em BIG up there, and I'm not just talkin Offensive Linemen... There was this Surgeon from Oshkosh... We used to say "Hey, Hey, Hey" (Theme from Fat Albert) before she'd back her huge backside through the OR doors... Funny thing is she does Bariatric Surgery...

Dr. Cosgrove also tried to boot McDonald's out of the main hospital. Combo Meal #4 includes a supersized BigMac meal and a triple bypass. McDonald's fought the lawsuit and won. You can rip the "evil empire" all you want but Dr. Cosgrove and Dr. Loop have done more for the economy of Cleveland than any politician. The public sector is a parasite that is close to killing their private sector host. I attached an article of a newly employed person at Scott's lawncare who was fired after testing positive for nicotine. People should recieve a lower rates for insurance for being a non-obese non-smoker. http://archive.southcoasttoday.com/daily/12-06/12-02-06/04state-region.htm

Wow. I'm always saddened by people with medical degrees who actually believe that weight is "simply" what you eat + how much you exercise. There is so, so much more involved. Genetics, medication, yo-yo dieting, stress, sleep schedules, there are 101 factors involved (at least). The most likely real reason that more people are "obese" is a combination of bad genes living longer (esp the diabetes/weight linked ones) and more sedentary lifestyles.

Yet despite the silly panics over the horrible "obesity epidemic" we're living longer -- and healthier. But the medial fat bigots don't want to hear that, nor believe it themselves.

As for being fat == bad heart stuff: Bunk. Try reading stuff from RN Sandy Schwarz: http://junkfoodscience.blogspot.com/2007/10/obesity-paradox-13-take-heart.html Maybe she didn't attend medical school but she seems capable of actually reading medical studies. She seems to understand that the "obese" aren't always a walking corpse-in-waiting, nor are they lazy idiots who need to be treated as such.

Yeah, medically treating someone with a very high BMI isn't a giant fun carnival ride, but neither is treating a homeless person who hasn't been able to change his clothes in a month or a person with dementia who can't control their bowels and thinks everyone is a stranger out to kill them.

It's *medicine* you folks signed up for, not king of the mountain. People like that need to be reminded to stop judging people and remember that they are human beings.

Moose-I can appreciate your frustration but let's try to avoid disingenuousness. Too often in this country we resort to hyperbole when engaging in discourse with someone we disagree with. Obama is a fascist. A racist. To toss around a pejorative term like "bigot" to describe an opponent who feels that a 60% overweight/obesity rate is a national problem and may be contributing to our healthcare cost woes simply marks you as unserious about engaging in useful dialogue. It isn't being "judgmental" to tell our patients that they need to lose weight. Our job is to objectively advocate for lifestyle alterations that will optimize a patient's health. If you want to hear that it's ok to be morbidly obese, look to self help support groups and sites like junkfoodscience----but dont expect doctors to fall into line....

For the record, I know a few obese docs - and actually a lot of overweight ones. So beyond the nurses, the docs & other educated professionals - who ought to know better - and have the resources - are contributing to this epidemic also.

The difficulty with discussing this topic is that the language quickly becomes ugly. Just read about this topic over at the Student Doctor Network. The young docs in training and wannabes are the worst offenders in this regard. The language they use to describe the obese is hideous. I am afraid for our future. Their blatant lack of compassion and righteous attitude is truly frightening. I can only hope that those who choose to post are not representative of the group as a whole. (But, I'm not that hopeful).

Obesity is many things, with many causes, it would seem. It is not "just" a matter of will power.

Certainly the farm subsidies the government pays contribute to it. The cheapest food is the often the worst for you. So, there are class and poverty components as well.

To be fair, using Dr. Cosgrove's model, he should not employ anyone with any controllable risk factors. Lipid panels will need to be monitored daily - alarms installed so that if an individual consumes any saturated fat, you automatically lose your job. Daily blood and urine tests - any doctor found to be abusing drugs (how many are there in his hospital - as many as in any other, I suspect) fired - immediately - no appeal.

We could create all kinds of criteria for health and punish everyone - if you have more than 1 drink per day - you're fired. If you inhale more than a set amount of pollutants, you're fired. If you ride a motorcycle, you're fired. If you have a gun in your home, you're fired. If you fail a psychology test showing any abnormality (whatever normal is - I'm guessing it's Dr. Cosgrove) you're fired. I could go on and on.

I agree that obesity must be combatted with the same force that brought down smoking as an acceptable behavior - but we must find a way to do it without further stigmatizing people who, however they got there, are human.

They struggle daily with this issue. They try and fail daily to be personally responsible for their behavior. They are our brothers, our mothers, our fathers our friends. They contribute to society. They are teachers, doctors, nurses and many other things that you never see, but whose absence would be felt were they not at their jobs. They are not monsters. Some compassion, please.

I applaud Dr. Cosgrove's courage to speak out the truth. If patient's could participate in the surgery of an obese patient, they could understand the difficulties involved with operating on those with obesity and the potential copmlications. Maybe that would make a good TLC episode?

Sorry, Doc, but I will indeed call a "bigot" someone who will go so far as to refuse to hire fat people. That's not helping the situation, it's helping to CAUSE it.

One of the facts about employment is that women are often paid less than men. Well studies have also found that fat people are not only paid less than their thinner, as-experienced peers but are also more likely to be unemployed. Why? Because despite studies showing the falseness of such beliefs, fat people are perceived as lazy, stupid, unmotivated, and without the ability to control themselves (because, of course, everyone *knows* they all overeat).

When my doctor tells me, "You would be more healthy if you lost weight," what can I do but agree? Of course I would! I've got a BMI (bad indication of health right there) of about 395823 and that surely contributes to many of my health issues. But when someone says, "Nobody should hire you because you're too fat" I say, "Bite me, bigot."

I may not be one of them but I've seen fat but physically fit people, all with BMIs that make them at least "obese", pass physically demanding tests to become prison guards, firefighters and police officers, and more. Hell, a good percentage of sports stars in the US is at least "obese."

The idea that obese people are that way because they simply eat too much and aren't active is simplistic and a sad belief for someone as educated as a medical doctor to have.

OK. Some people do have patho/phys/meds that contribute to difficulty in managing weight. This is not being denied. However, the overwhelming majority of this group can manage diet/exercise and avoid obesity with guidance. There are many more who try to place themselves in this group, but simply do not qualify.

As for the obese docs, RNs well... since they are human, they also try to blame it on the same stuff everybody else does.

And, I'll share that at hospital, I do question work ethic in certain staff. I need you to haul your a$$ when I page ya! Just sayin.

Moose- Hiring practices that discriminate solely against weight at a non-profit institution like the Cleveland Clinic is unsupportable. But advocating for social/governmental measures that put pressure on the obese to alter their lifestyle choices is NOT bigotry. Obesity is an epidemic in this country. Undeniable too are the secondary costs accrued from morbid obesity (DMII, HTN, severe osteoarthritis, venous stasis, higher complication rates in surgery, etc). Certainly its a more difficult issue to address than tobacco abuse because we're not talking about a cancer stick that hangs out of your mouth, we're talking about asking someone to look in the mirror and acknowledge that what they see is unhealthy, suboptimal. So naturally there will be a psychological sting anytime you demand of certain subpopulations to engage in what is essentially a form of self-denigration. It's hard. Feelings are going to be hurt. But we need to stop ignoring the elephant in the room. It doesn't mean physicians ought to be insensitive. Compassion is still mandatory. But we can't continue as Fast Food Nation indefinitely....

Subpopulations Malthus? Wow, why don't you just let the people kill themselves from the overconsumption of fast food. In a free society people should be allowed to do as they please as long as it doesn't hurt anybody else. They should also be willing to pay the costs of those choices and not expect other taxpayers to pay for their bad choices.

Hmmm...smoking is a choice, eating isn't. Something like 40,000 people work in the Cleveland Clinic system. If the obesity rate is currently at 31%, that means about 12,400 people working there already are obese. How can Dr. Cosgrove deal with it?

According to my limited legal knowledge Michigan is the only state in which it is illegal to have an anti-obesity hiring policy.

Moose - unfortunately while obesity is multifactorial simple basic truths remain. One is that using more calories than oneingests will definitively lead to weight loss, there are no two ways about this. There are many factors that make this more or less difficult for individuals, though that is at least partially true for many diseases.

One big issue in all of this is exercise. Ill find the link if someone wants but JACC had an article looking at sedentary lifestyle versus obestiy andfound that for cardiac risk sedentary life styles have a much higher odds ratio for CV disease than obesity does. So we should attack the obesity epidemic but while realizing that the real culprit IMO is inactivity.

A Cleveland Clinic employee who is fat should pay higher insurance premiums. Most people are fat because they eat too much. Don't give me this BS about an overative thyroid. Everyone has seen the documentary where the guy eats McDonalds for a month and his liver is more inflammed then an alcoholics. Get rid off the all beef hotdogs and put the Hagen Das down.

Well I think everyone knew 2 years ago when they stopped hiring smokers, this would be their next step.

You know, many of the countries obese, are poor people. It is cheaper to eat high calorie foods than it is to eat healthy. The reasons many older people stay heavy is because they run out of money about the 3rd week of every month. instead of buying and eating fruits and vegetables they eat bread and pasta. They can buy a loaf of bread which will last several days or a pound of pasta which will also do for several meals for the price of (1) peach.

The fruit stand on the corner were selling tomatoes and peaches for 1.00 each. the grocery was selling bread and pasta for .99 each. It is not that so many people overeat, but rather what they eat.

Now if someone wants to figure out how to make sure everyone can afford all this healthy food every day, then they can talk not hiring obese people. But, unless he can come up with a solution to cure obesity, and a way to make it happen, he needs to give up on this.

There are some overweight people who are healthy and happy. Who are you, or him, or anyone else to tell them what they must do?

Why is it they want to attack smokers and weight issues but yet...no one much mentions the idea of not hiring alcoholics? Is it OK to destroy your liver? Is it proper to this employer to have workers who get in a car drunk and kill a few people? Is it OK to get in a drunken rage and beat up wives or girlfriends? How many medical issues is there related to alcohol? How many medical dollars are used each year to treat consequences of alcohol? How many days are missed at work for alcohol related issues? How many lives have been taken every single year by alcoholics and drunk drivers?

A person becomes obese over the years because of excessive eating. But if one will have the courage to shed those fats then it will also take some years. Persistence is necessary to gain back the healthy body to avoid unwanted complications. -----Fat Loss Facts

I work in a hospital and see obese patients coming through, and I just want to cry at how difficult they make it for the staff. The denial of the overweight and obsese is what is truly frightening. It is simple math: if you are overweight, you are consuming more calories than you are burning. If you have any other excuse for your high BMI, seek mental help immediately.

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